One of the issue of the Czech reimbursement regulation of medical devices has always been related to the health insurance companies' codebooks. These are tools used for input registration, allocation of reimbursement from health insurance, reporting and control. For many years this system worked, but after the pressure for savings in the field of medical technology intensified, this well-oiled machine started to grind to a halt. This first became apparent in the case of medical devices prescribed on vouchers, where the Constitutional Court struck down the existing legislation on the grounds that the rules contained therein led to non-transparent and non-reviewable reimbursement determinations. In January 2019, an amendment to the Public Health Insurance Act came into force, which set new rules and entrusted the reporting of medical device reimbursements to the health insurance companies continue to issue the voucher, but they must respect the system-wide reimbursement catalogue issued by SÚKL every month.
We are now getting to a situation where the ZUM codebook management system is also starting to be outdated. There are a number of reasons for this. The first is purely formal, namely that health insurers have no legal authorisation to set maximum commercial prices. The second reason is the double-track nature of the historical regulation represented by the codebook and the new, gradually prevailing way of regulating hospital care reimbursement through the CZ-DRG. Codebook values, such as the maximum reimbursement amount, made sense in a situation where all ZUM was actually separately reported and separately reimbursed. Today, this is only the case for so-called outpatient ZUM and in a few other completely insignificant cases.
It turns out that the efficiency of regulation through ZUM codebooks lags far behind the extreme laboriousness of this whole agenda. Yet it is sufficient for the MoH to adjust, for example, the basic rate in the reimbursement decree. In the event of an increase in the rate, health insurance companies will not save a single crown, and on the contrary, in the event of a decrease, they will save a lot of money without having to conduct "price negotiations" on the inclusion of each individual ZUM item. The current discussions of all stakeholders at the MoH clearly show how difficult it will be to reconcile the so far rather contradictory ideas about the future of the ZUM codes.
Author: Jakub Král